616281181
The Achilles tendon, the largest tendon in the human body, is formed by a combination of the gastrocnemius and ray muscles , which together connect to the foot in the area of the calcaneal tuberosity. Among other things, thanks to this anatomical structure, a person can flex the sole of the foot, and thus: climb on the toes, walk, run or jump. Although the Achilles tendon is made up of many collagen fibers, making it very strong, that does not at all mean that it is fully immune to inflammation or damage. Inflammation of the Achilles tendon is a common injury to runners and people who participate in sports that rely on running.
Achilles tendonitis - causes.
Achilles tendonitis most often occurs in people who have suddenly and without prior preparation subjected themselves to excessive physical exertion, or in obese people with a sedentary lifestyle. On the other hand, in people involved in amateur or competitive sports, Achilles inflammation can be associated with a large accumulation of micro-injuries in a short period of time. At risk are athletes who run on hilly terrain - when there is a large number of uphill runs (toe bounce) and downhill runs (deceleration). Inflammation of the Achilles tendon can also be triggered by changing shoes to those whose sole is too stiff and the heel counter too flexible - not providing proper heel stabilization. That's why it's so important to properly select running shoes and fit individual orthotic insoles. Achilles tendon ailments may be experienced by elderly people, in whom, with age, the elasticity, and therefore the mechanical strength of the tendon and the triceps calf muscle, decreases.
Achilles tendonitis - symptoms.
- The main symptom of inflammation is pain in the Achilles tendon in the lower calf.
- Most often it is the so-called morning Achilles pain, right after getting out of bed.
- In athletes, the burning Achilles pain appears at the beginning of exercise, decreases during exercise and increases again after training.
- In the case of inflammation of the Achilles tendon attachment, pain may occur at night when
- sleeping resting the foot on the heel.
There may also be stiffness of the foot tendon. - There is a pronounced tendon tenderness when the toes are pressed a few centimeters above the heel.
- In a chronic condition, a painful thickening can be felt on the Achilles tendon.
- Reduced ability to dorsally flex the ankle and shin joint (to step the foot up).
The risk of inflammation of the Achilles tendon can be reduced by performing regular stretching exercises, and starting any physical activity calmly, with a gradual increase in load.
Achilles tendonitis - diagnosis
The basis for diagnosing overload lesions of the Achilles tendon, often referred to as "Achilles tendonitis," is a clinical examination supported by ultrasound, explains Dr. Joanna Niemunis-Sawicka of Rehasport. The ultrasound examination evaluates the morphology and continuity of the tendon, as well as the vascularization of the tendon. Dynamic ultrasound evaluates its mobility, as well as the mobility of the tendon relative to surrounding tissues. Rarely, magnetic resonance imaging is used, which can be performed mainly to visualize the extent of inflammatory complications, such as after surgery, or to evaluate intra-articular changes in the heel attachment of the tendon, especially in rheumatologic conditions. X-ray, when we have inflammation of the Achilles tendon, has little diagnostic value in the evaluation of soft tissues, while it perfectly shows the shape of the calcaneal attachment of the tendon, or possible bony changes, both in the attachment itself and in the entire calcaneus.
Despite such well-developed imaging diagnostics (ultrasound, MR, X-ray), when examining Achilles tendonitis, it is very important in making a diagnosis to carefully interview the patient to find out the nature of the pain, at what activities it intensifies or subsides. A thorough clinical examination will help initially assess the condition of the tendon and guide further management and decide whether the patient needs an imaging study and what kind of diagnosis and treatment is required.
Achilles tendonitis conservative treatment
These can be divided into rehabilitation exercises, injections into the Achilles tendon area and physical therapy.
Scientific research for many years has confirmed the very good effectiveness of rehabilitation exercises in the treatment of Achilles tendonitis. Such treatment lasts about 12 weeks, until the Achilles tendon pain is no longer felt. It involves properly guided, multi-stage rehabilitation to reduce pain and, through proper activities and cycles of the Achilles tendon and calf muscles, improve its ability to tolerate greater loads.
The most effective exercises are those that stretch the Achilles tendon under constant tension of the gastrocnemius and patellar muscles and progressively increasing the load during exercise. In a nutshell, the initial stage of treatment consists of isometric exercises performed several times a day to relieve pain in the Achilles tendon. Subsequent stages involve exercising the triceps calf muscle under constant tension to increase muscle mass and strength, and finally the ability of the Achilles to perform the activities we practiced before the onset of the condition.
Achilles tendon injections should only be used as a complementary treatment for patients whose Achilles tendon pain has not resolved after 12 weeks of properly managed rehabilitation.
Unfortunately, there is still a lack of scientific evidence to unequivocally confirm the effective effect of such treatments. We know that the administration of so-called steroid "blocks" of the Achilles tendon, worsens the effects of tendonitis treatment. Preparations with platelet-rich plasma (PRP), or stem cells (bone marrow blood, fibroblasts) do not show effectiveness greater than the placebo effect. Sclerotherapy, popularly used to remove varicose veins of the lower extremities, may be effective. It causes excessive congestion in the area of the affected Achilles to close and fibrate, resulting in a less swollen and painful tendon.
Treating Achilles tendonitis conservatively can also include physical therapy. The use, in conjunction with rehabilitation exercises, of physical therapy treatments such as shock wave therapy or laser therapy can be very helpful. These have proven effectiveness backed by scientific studies.
If the Achilles tendon pain is mild and the possibility of getting to an orthopedist or physiotherapist is difficult, it can be relieved with ad hoc ointments or gels with analgesic and anti-inflammatory effects. Periodic relief is also provided by cold compresses, but it should be borne in mind that such treatment temporarily reduces the symptoms, but does not combat the cause of the problem.
Achilles tendonitis - surgical treatment
Although Achilles tendonitis can be in a chronic state, we use surgical treatment very rarely and only in cases where months of Achilles tendon rehabilitation protocols have proved ineffective. Before surgery, we perform an MRI scan of the Achilles tendon to determine the extent and exact location of the abnormal tissue. Surgery for chronic Achilles tendonitis involves removing adhesions around the Achilles and clearing the tendon of foci of degenerated tissue. This procedure can be performed through a classic skin incision of several centimeters in length, or by a minimally invasive technique through several small skin incisions through the use of endoscopic tools such as we use in arthroscopic procedures. When large defects in the tendon are created after clearing the diseased tissue, we strengthen the tendon by placing sutures over the tendon. Special plastic techniques are also used by moving fragments of the tendon in place of the defect, in extreme cases we support the diseased tendon by moving-transferring another tendon of the shin muscle in place of the Achilles. Each procedure is individually planned and tailored to the severity of the patient's condition. When treating Achilles tendonitis, minimally invasive techniques are preferred, as they generate fewer complications and allow faster mobilization of the operated limb compared to the "classic" technique. After surgery, we wait about 6 weeks for the tendon to heal before the patient can perform rehabilitation with weight bearing on the operated tendon.
We consider the condition healed when the patient is free of pain and stiffness in the tendon after returning to physical activity.
Watch out for:
- increasing running loads too quickly,
- resuming training too soon after an injury,
- conducting workouts without a warm-up,
- too many uphill or staircase runs during workouts,
- a sudden change in the surface on which one runs - from soft to asphalt.
Achilles tendonitis - rehabilitation
If you are diagnosed with Achilles tendinopathy (Achilles tendonitis), you should reduce the intensity of your training. When this does not bring positive results, physical activity should be completely stopped for a period of several days, or even extend the break to two weeks. In order not to strain the Achilles tendon, one should also refrain from running (e.g., running up to the bus) and walking in high heels. You can also cool the painful area with a cooling gel.
Chronic Achilles tendonitis - cooling.
Achilles tendonitis - exercises
Achilles tendonitis - rolling the triceps calf muscle. The exercises are presented by Magdalena Paszko of Rehasport. It is necessary to drive the roller slowly through the entire length of the calf, up to the popliteal fossa (without going through it). Feeling a painful point, indicates that you have come across the right spot, where you should stop and try to roll it in a short back and forth motion until the pain disappears.
Achilles tendonitis - the Alfredson protocol
Regular performance of eccentric exercises (work of the muscle, during which its length increases) for the triceps calf muscle with this condition, is very effective. The exercises are performed twice a day for a period of 12 weeks. The first is performed with the knee joints straightened, and the second while they are bent to 45 degrees. The task is to climb up on the toes on both feet, and then slowly lower only on the injured leg. Using the Alfredson protocol, the exercises are performed in 3 series of 15 repetitions, with a break of about 1 minute between series.
Achilles tendonitis - return to physical activity
Once the Achilles tendon pain subsides, a gradual return to physical activity is recommended. If symptoms of Achilles tendonitis reappear, you should stop doing activities that cause pain. After a few days' break, you can return to physical activity, but reducing the training load, additionally strengthening the tendon with the exercises you performed during the last stages of rehabilitation.
Related articles:
Learn about other possible injuries to the foot and ankle joint.
Bibliography:
- Demangeot Y, Whiteley R, Gremeaux V, Degache F. The load borne by the Achilles tendon during exercise: A systematic review of normative values. Scand J Med Sci Sports. 2022 Oct 24. doi: 10.1111/sms.14242. Epub ahead of print. PMID: 36278501.
- Malliaras P. Physiotherapy management of Achilles tendinopathy. J Physiother. 2022 Oct 20:S1836-9553(22)00089-3. doi: 10.1016/j.jphys.2022.09.010. Epub ahead of print. PMID: 36274038.
- Johnson LG, Buck EH, Anastasio AT, Abar B, Fletcher AN, Adams SB. Efficacy of Platelet-Rich Plasma in Soft Tissue Foot and Ankle Pathology. JBJS Rev. 2022 Oct 3;10(10). doi: 10.2106/JBJS.RVW.22.00059. PMID: 36191089.
- Piontek T, Bąkowski P, Ciemniewska-Gorzela K, Grygorowicz M. Minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization. BMC Musculoskelet Disord. 2016 Jun 3;17:247. doi: 10.1186/s12891-016-1099-3. PMID: 27256340; PMCID: PMC4891922.
